Tahlil et al.

BMC Public Health (2015) 15:1088

DOI 10.1186/s12889-015-2428-4

RESEARCH ARTICLE Open Access

Six-months follow-up of a cluster randomized

trial of school-based smoking prevention
education programs in Aceh, Indonesia
Teuku Tahlil1*, Richard J. Woodman2, John Coveney3 and Paul R. Ward3

Abstract
Background: Smoking prevention programs have been taught in schools to reduce the high smoking prevalence
and its related problems among adolescent populations. Although short-term benefits have been observed, the
long-term effectiveness of such programs appear to be inconsistent. This study aims at investigating the long-term
impact of both health and Islamic focused interventions amongst students in Indonesia.
Methods: At 6 months after completion of the interventions, 427 of the original 447 participants (control group = 128,
intervention groups = 299) from a school-based cluster randomized control trial were re-assessed for their smoking
knowledge, attitudes, intentions and behaviours using a self-report questionnaire. Data was analyzed according to the
study’s 2 × 2 factorial design with adjustment for baseline scores, school and classroom clustering effects and multiple
comparisons.
Results: Compared to the control group, significant long term effects were found for the health-based intervention
program in improved health (β = 4.3 ± 0.4, p < 0.001), Islamic (β = 1.1 ± 0.4, p = 0.01) knowledge and a reduction of
smoking attitudes (β = −11.5 ± 1.8, p < 0.001). For the Islamic-based intervention programs there was an improvement
of health (β = 3.7 ± 0.4, p < 0.001) and Islamic (β = 2.2 ± 0.5, p < 0.001) knowledge and a reduction towards smoking
attitude (β = −6.0 ± 1.9, p < 0.01) and smoking behaviors in the past month (OR = 0.1, 95 % CI = 0.0–0.8, p = 0.03). The
effects were greater but less than additive in the combined group for health (β = −3.2 ± 0.9, p < 0.001 for interaction)
and Islamic knowledge (β = −2.3 ± 0.9, p = 0.01 for interaction) but were additive for smoking attitudes (β = 6.1 ± 3.2,
p = 0.07 for interaction). No significant effects on smoking intentions were observed at 6 months follow-up in the
health or Islamic-based intervention programs.
Conclusion: School-based programs can provide long term benefits on Indonesian adolescents’ smoking knowledge
and attitudes. Tailoring program intervention components with participants’ religious background might maximise
program effectiveness. A larger and more encompassing study is now required to confirm the effectiveness of this new
Indonesia culturally-based program. Adolescents in similar areas might also benefit from this type of school-based
smoking cessation program.
Trial registration: Australian New Zealand Clinical Trial Registry, ACTRN12612001070820
Keywords: School-based program, Tobacco smoking, Adolescents, Muslim context, Indonesia

* Correspondence: teuku.tahlil@flinders.edu.au
1
Nursing Faculty, Syiah Kuala University, Banda Aceh 23111, Indonesia
Full list of author information is available at the end of the article

© 2015 Tahlil et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
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the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Tahlil et al. BMC Public Health (2015) 15:1088
Background
Much progress has been made concerning the imple-
mentation of tobacco control measures worldwide [1],
but tobacco use and its associated harms remains high
across the globe. Worldwide, over 1.3 billion people
smoke [2], around 6 million have died due to tobacco
and annually over half a trillion dollars is spent globally
to cover monetary loss due tobacco-related effects [1].
Tobacco smoking causes many diseases [3] and is ac-
counting for 8.4 % of disease burden among men and
3.7 % among women [4].
Indonesia is the world’s third largest country in tobacco
consumption [5]. Approximately 29.3 % of Indonesians
smoke tobacco (64.9 % of males and 2.1 % of female) [6].
Indonesians smoke about 12.3 sticks of tobacco per day
[6] and spend about 6.3 % of their income on tobacco [7].
The prevalence rates of current tobacco use among
adolescents are 13.5 % (24.1 % for boys, 4 % for girls) [5].
Despite the high proportion of tobacco smoking, to-
bacco control measures are currently very weak within
Indonesia [1].
Following observed benefits from short-term school-
based smoking cessation programs, there has been an
increasing focus on examining the longer term effective-
ness of such programs. Although numerous programs
over the past 40 years have been developed [8], findings
of systematic reviews provide different conclusions about
the long-term effectiveness of school-based smoking
prevention programs with one review of 8 randomized
trials with follow-up by age 18 or grade 12, at least
1 year after program intervention completion, conclud-
ing there was insufficient long term evidence to recom-
mend school-based smoking prevention programs [9].
Conversely, other reviews [10, 11] had suggested there
was evidence for long-term effectiveness of school-
based smoking prevention programs.
We have previously developed and tested three types
of school-based smoking prevention programs compris-
ing a health, Islamic, and combined health and Islamic-
based program amongst adolescents in a western area of
Indonesia [12]. The immediate effects of the programs
which showed positive improvement in participants’
smoking knowledge, attitude, intentions, and behaviours
at one week after the programs completion have been
reported elsewhere [12]. The current paper assesses the
program’s effectiveness at 6 months follow-up. Evalu-
ation included a re-assessment of the participants’ smok-
ing knowledge, attitudes, intentions, and behaviours.
Methods
Design and randomization
Eight junior high schools from the capital of Aceh Prov-
ince, Indonesia were recruited for participation. Two
classes in each school with about 15 to 16 students per
Page 2 of 10
class were selected and assigned to one of the three inter-
vention arms (the health, the Islamic, or the combined
program) or to a control arm. The selected schools were
approved by the head of the education department in the
district and randomized using random number generation
procedure in Excel. There was no difference between
schools in terms of schools location, students size and
their background characteristics. Additional information
about the school selection process, characteristics and
randomization procedures can be read elsewhere [12].
All school students completed three waves of program
evaluation: (1) Baseline: one week before intervention,
(2) Post-intervention: within 1 week of the 8-week inter-
vention completion (3) 6 months follow-up: 6 months
after the intervention completion (8 months after base-
line). Students in the intervention groups received eight
sessions of smoking prevention education. Students in
the control group received no education intervention.
Participants
Study participants comprised adolescents aged between
11 and 14 years. A power calculation was conducted
based on mean and changes and standard deviations of
knowledge scores (as the primary outcome measure)
from a pilot study. This showed that the required sample
size was 480 to provide 80 % power for comparing group
differences at a 2-sided alpha level of 0.05 [12]. Initially a
total of 477 students participated in the study. Of the
477 students, 476 (99.8 %) completed program evalu-
ation at baseline and following intervention and 427
(89.5 %) provided information at all 3 program evalu-
ation time-points. The retention rates at 6 months for
the individual groups were 109 (89.3 %) for the health-
based program; 101 (92.7 %) for the Islamic-based pro-
gram; 110 (94.0 %) for the combined program, and; 107
(83.6 %) for the control group. Reasons for dropout
included absenteeism, school events, leaving or transfer-
ring to other schools. Figure 1 provides detailed propor-
tions of the study participants by group assignment
throughout the study process.
Interventions
Program interventions were developed on the basis of
systematic review of available school-based smoking pre-
vention programs worldwide, published between 2004 and
2009. This review focused on trends in school-based
smoking prevention programs, and then synthesized find-
ings of this review into what is called the Health-Based
Intervention program in this study. We also reviewed all
available literature on religious based education programs,
including those relating to smoking prevention and cessa-
tion, and synthesized these into what is called the Islam-
based Intervention. Additionally, a qualitative research
with teachers and policy makers in education from Aceh,
Tahlil et al. BMC Public Health (2015) 15:1088
Fig. 1 Study Participants by groups from baseline to 6 months follow-up
Indonesia, was conducted in order to develop more cul-
turally appropriate interventions and match with current
curricula [13]. The programs employed both social influ-
ence and competence curricula. The health-based pro-
gram provided students health-based information and
skills surrounding smoking prevention including informa-
tion about historical perspective of tobacco smoking and
smoking behaviours in Indonesia, tobacco smoking ef-
fects, national regulation about tobacco smoking, refusal
skills, assertiveness, and stress management. The Islamic-
based program taught students information and relevant
skills about smoking prevention from an Islamic perspec-
tive, and this included information about Islam; tobacco
smoking among Islamic society; Islamic view about
health, tobacco smoking, and healthy living techniques.
The combined program comprised key concepts of the
health- and the Islamic-based approaches including the
Islamic concept, historical perspective of tobacco smok-
ing in Indonesia, effects of tobacco smoking, Islamic
and national rules on tobacco smoking, refusal skills,
and healthy living techniques in Islam.
The curricula were divided into eight two-hour sessions
and administered in the students usual classrooms during
school hours. Program providers included school teachers
and health professionals for the health-based program;
Islamic leaders and school teachers with in-depth know-
ledge in Islamic teaching about smoking prevention for
the Islamic-based program, and; the combination of
school teachers, health professionals, and Islamic leaders
Page 3 of 10
for the combined program. The schools integrated pro-
gram activities into relevant school subjects. Providers
used various interactive teaching methods that were cul-
turally appropriate to students such as group/class discus-
sions, brain storming, role play, and storytelling. One day
training and program material including teaching material
and instruction were provided to providers and students
in order to prevent any biases in program delivery and
contents. Also, meetings and supervision were conducted
during program implementation, to ensure that program
implementation was carryout as planned. Further explan-
ation about program content and delivery methods can be
found elsewhere [12].
Data collection and measures
Data were collected using a paper-based, close-ended re-
sponse questionnaire. This self-report questionnaire was
conducted at each of the study’s three data collection
time-points. Students completed the questionnaires in
their classrooms during school hours which lasted about
80 min. To ensure that students could honestly provide
their responses, students were informed about the confi-
dential nature of their responses. Also, no school teacher
or administrators were involved in these tests. Research
staffs with the help of external program providers, who
were both not affiliated with the schools, administered
the tests under the supervision of researchers. There
was no school teacher and school staff in class room
during the tests.
Tahlil et al. BMC Public Health (2015) 15:1088
Overall, the questionnaire assessed demographic charac-
teristics of the study participants and program outcome
measures. The development process of the questionnaire
has been previously explained elsewhere [12]. This reports
on the development of the primary outcome measures
which were an assessment of participants’ smoking know-
ledge, attitude, intentions, and behaviours. These com-
prised relevant questions from previously valid and reliable
questionnaires and were complemented with questions
specifically designed for assessing the Islamic-based know-
ledge outcomes. The instruments were pilot tested for
validity, internal reliability and test-retest validity with a 2
week interval between tests.
It has been previously reported [12] that the question-
naire comprised 71 items, these included: (1) 4 items for
assessing students’ demographic participants; (2) 20
items for assessing health knowledge outcome (Cronbach’s
alpha was 0.88 at Test 1 and 0.90 Test 2, kappa between
0.08 and 0.53); (3) 20 items for assessing Islamic know-
ledge outcome (Cronbach’s alpha was 0.79 at Test 1 and
0.88 Test 2, kappa between 0.02 and 0.66); (4) 25 items for
assessing smoking attitudes outcome (Cronbach’s alpha
was 0.87 at Test 1 and 0.86 Test 2, kappa between 0.02
and 0.52); (5) 3 items for assessing smoking intentions
outcome (Cronbach’s alpha was 0.74 at Test 1 and 0.84
Test 2, kappa between 0.35 and 0.49); (6) 3 items for
assessing smoking behaviours outcome (Cronbach’s
alpha was 0.88 at Test 1 and 0.80 Test 2, kappa
between 0.77 and 0.79).
Demographic information included sex, age (in years),
year of study (in grades), and living conditions (with
both parents, one parent and stepfather/mother, one
parent only, relatives, or others). The program outcome
measures were focused on smoking knowledge, atti-
tudes, intentions and behaviours. The knowledge out-
come was divided into a health and an Islamic section
(20 items each) and formatted as multiple choice ques-
tions. The health section measured participant’s know-
ledge about the negative effects of tobacco smoking,
national tobacco smoking prevalence and its regulation
in Indonesia. The Islamic section measured participant’s
knowledge about Islamic concepts, Islamic views about
health, tobacco use and regulation among Muslims.
The smoking attitude section asked participants to
indicate their agreement on 40 positive/negative state-
ments about the physical, social and economic effects of
tobacco smoking and tobacco smoking policy. The items
to measure this variable were rated on 5-point Likert
scales, ranging from 0 (strongly disagree) to 4 (strongly
agree). The smoking intentions were measured by three
items assessing participant’s intention to smoke tobacco
next year, during senior high school and when older.
These items were rated on 5-point Likert scale, ranging
from 0 (certain not to smoke) to 4 (certain to smoke).
Page 4 of 10
The smoking behaviours assessed the amount of tobacco
consumed by a participant in the past week, month, and
lifetime. Potential responses ranged from 0 (never
smoked) to 4 (three to five cigarettes) for the past week’s
smoking; 0 (never smoking) to 6 (more than 20 ciga-
rettes per day) for the past month’s smoking; and 0
(never smoking) to 8 (over 100 sticks of cigarettes) for
lifetime’s smoking. The majority of questions for the
health-related aspects of smoking were adopted from
previous studies [14–24] and matched with educational
material of the current study and cultural background of
the study participants. Items for the Islamic knowledge
aspect were based on program materials. The question-
naire appeared to be valid and reliable [12].
Ethical approval
The Social and Behavioural Research Ethics Committee
(SBREC) of Flinders University, Australia and the Ethical
Clearance Committee of Medical Faculty of Syiah Kuala
University, Indonesia provided ethical approval for the
study. Written consents for participation from schools’
principals, parents/guardians/significant others, and stu-
dents were requested. The students were informed about
the study’s purposes, procedures, potential risks and
benefits, and other ethical consideration including the
voluntary nature of their participation by oral and infor-
mation sheet.
Data analysis
Data analysis was performed using Stata version 12.0
(StataCorp, Texas, USA). Between groups comparisons
of demographic information was assessed using chi-
squared tests. Differences between groups at baseline of
the outcome variables was assessed using Analysis of
variance (ANOVA) for smoking knowledge and attitude,
and using chi-squared tests for smoking intentions and
behaviours. The main effects of Health and Islam pro-
grams and the interaction between Health x Islam at
6 months were assessed using generalized linear models
with the 6 month outcome variable as the dependent
variable and with indicator variables for Health and
Islam, and a Health x Islam interaction term and a term
for baseline scores. The degree of clustering within
classrooms and schools for each outcome was assessed
using mixed effects regression models with classroom
and school identifiers added as random effects. Intra-
class correlation coefficients (ICC) were used to report
the clustering effects. An additional Analysis of Covari-
ance (ANCOVA) with Bonferroni-adjustments for com-
parisons of the 3 intervention groups with the control
group was conducted to aid interpretation of the study
findings. Further explanation of the data analysis proced-
ure has been described in detail elsewhere [12].
Tahlil et al. BMC Public Health (2015) 15:1088 Page 5 of 10

Results participants within the same classroom (ICC = 0.10) indi-

Characteristics of participants at 6 months follow-up cating that there was an additional classroom effect in
Table 1 compares background characteristics of the 427 addition to an individual learning effect. Groups’ differ-
study participants at 6 months follow-up. Overall, par- ences in health knowledge are presented in Fig. 2 and
ticipants were mostly girls (58.8 %) seventh graders Table 3. There were significantly greater health knowledge
(50.1 %), mostly aged over 12 years (92.8 %) and lived scores after adjusting for baseline (p < 0.001) for all 3
with both parents (80.8 %). There were no significant intervention groups when compared to control group
differences between the intervention groups and the (Table 3).
control group (all p > 0.05).
Program effects on Islamic knowledge at 6 months
Program effects on knowledge at 6 months follow-up follow-up
The main effects and interaction effects of the health Main effects and interaction effects of the health and
and Islamic-based intervention programs on health and Islamic-based intervention programs on Islamic know-
Islamic knowledge at 6 months follow-up are presented ledge at 6 months follow-up are shown in Table 2.
in Table 2. There was a significant main effects of the Main effects of the interventions appeared to be sig-
health (β = 4.3 ± 0.4, p < 0.001) and Islamic-based inter- nificant for the Islamic (β = 2.2 ± 0.5, p < 0.001) and
vention (β = 3.7 ± 0.4, p < 0.001) on health knowledge health-based intervention (β = 1.1 ± 0.4, p = 0.01) at
improvement at 6 months follow-up compared to the 6 months follow-up compared to the control group.
control group. Interaction effects between health and There was a significant interaction between health and
Islamic-based intervention were significant (β = −3.2 ± 0.9, Islam (β = −2.3 ± 0.9, p < 0.01), suggesting that the ef-
p < 0.001), suggesting that the effect of the combined pro- fects of the combined program on Islamic knowledge
gram on health knowledge depended upon inclusion of depended upon inclusion of the health-based interven-
Islamic-based intervention component and vice versa, i.e. tion component and vice versa, i.e. the effects were sig-
the effects were not completely additive in the combined nificantly less than additive in the combined group.
group. The effects were relatively homogenous between The effects were more homogenous for participants
within the same class (ICC = 0.09). Groups’ differences
Table 1 Characteristics of participants by groups at 6 months in Islamic knowledge at 6 months follow-up are pre-
follow-up visit
sented in Fig. 2 and Table 3. There were differences
Characteristics Health Islamic Combined Control p valuesa
(n = 109) (n = 101) (n = 110) (n = 107)
between the intervention and control groups in Islamic
knowledge scores at 6 months, with the scores signifi-
Sex 0.92
cantly higher in the Islamic-based program, but not in
Boys (%) 42.6 42.2 38.5 41.4
the health-based or combined programs, when com-
Girls (%) 57.4 57.8 61.5 58.6 pared to control group (Table 3).
Age
11 years (%) 1.6 1.8 2.6 0.8 0.50 Program effects on smoking attitudes at 6 months
12 years (%) 23.0 32.1 31.6 38.3 follow-up
Main effects and interaction effects of the health and
13 years (%) 48.4 45.9 42.7 39.8
Islamic-based intervention programs on smoking atti-
14 years (%) 27.0 20.2 23.1 21.1
tudes at 6 months follow-up are presented in Table 2.
School grade Main effects of the interventions were significant for the
7th (%) 45.9 51.4 51.3 47.7 0.81 health (β = −11.5 ± 1.8, p < 0.001) and Islamic-based
8th (%) 54.1 48.6 48.7 52.3 intervention (β = −6.0 ± 1.9, p < 0.01) at 6 months
Residence status follow-up. There was no significant interaction effects
(β = 6.1 ± 3.2, p = 0.07) between the health and Islam at
With both 88.5 89.0 77.8 80.5 0.10
parents (%) 6 months follow-up, suggesting that there were no dif-
With one 0.8 0.9 6.0 2.3
ferential effects on the reduction of smoking attitude
parent and scores for both the health and Islamic based interven-
step parent (%) tions, i.e. the effects were additive in the combined
With one 5.7 6.4 10.3 6.3 group. The effects were more similar for participants
parent only (%) within the same class (ICC = 0.07). Groups’ differences
With relatives 4.1 3.7 4.3 8.6 in smoking attitudes at six months are presented in
(%) Table 3 and Fig. 2. Table 3 shows there were significant
Others (%) 0.8 0 1.7 2.3 differences (p < 0.001) between groups in smoking atti-
a
using chi-squared test of association tude at 6 months follow-up, with the three intervention
 Tahlil et al. BMC Public Health (2015) 15:1088
Table 2 Knowledge and attitude scores, intentions and behaviors at 6 months follow-up and the baseline adjusted program effects (β) (n = 427)
Outcomes Health intervention Islamic intervention Health x Islamic ICCf
Interaction
Health (n = 219) Non health (n = 208) β ± SEa p valued Islamic (n = 211) Non Islam (n = 216) β ± SEb P valued β ± SEc p valuee
(mean ± SD) (mean ± SD) (mean ± SD) (mean ± SD)
Health Knowledge 11.1 ± 1.9 10.2 ± 2.6 4.3 ± 0.4 <0.001 11.3 ± 2.0 10.1 ± 2.5 3.7 ± 0.4 <0.001 −3.2 ± 0.9 <0.001 0.10
Islamic Knowledge 11.7 ± 2.7 13.0 ± 2.4 1.1 ± 0.4 0.01 13.2 ± 2.7 11.6 ± 2.3 2.2 ± 0.5 <0.001 −2.3 ± 0.9 <0.01 0.09
Attitude 38.8 ± 7.3 38.2 ± 8.6 −11.5 ± 1.8 <0.001 36.7 ± 7.1 40.3 ± 8.4 −6.0 ± 1.9 <0.01 6.1 ± 3.2 0.07 0.07
Health intervention Islamic intervention Health x Islamic ICCf
Interaction
Health n (%) Non health n (%) OR (95 % CI)a p valued Islamic n (%) Non Islam n (%) OR (95 % CI)b p valued
Intention to smoke next 10 (4.6) 16 (7.7) 0.4 (0.1,1.3) 0.14 8 (3.8) 18 (8.3) 0.4 (0.1,1.6) 0.20 * 0.12
year
Intention to smoke in 13 (5.9) 20 (9.6) 0.4 (0.1, 1.3) 0.13 9 (4.3) 24 (11.1) 0.3 (0.1, 1.2) 0.10 * 0.12
senior high school
Intention to smoke over 17 (7.8) 22 (10.6) 0.5 (0.2, 1.2) 0.13 15 (7.1) 24 (11.1) 0.6 (0.2, 1.4) 0.24 * 0.07
50
Past week smoking 3 (1.4) 4 (1.9) 0.5 (0.2,1.5) 0.24 0 (0) 7 (3.2) 0.0 (0) ** * 0.24
Past month smoking 6 (2.7) 8 (3.9) 0.4 (0.2, 1.0) 0.04 1 (0.5) 13 (6.0) 0.1 (0.0, 0.8) 0.03 * 0.10
Lifetime smoking 51 (23.3) 45 (21.6) 0.9 (0.4,2.2) 0.84 33 (15.6) 63 (29.2) 0.5 (0.2, 1.3) 0.16 * 0.15
Note: The groups were classified into two factors: (1) Islam (Islamic-based program), which comprises the Islamic and combined groups, (2) health (health-based program), which comprises the health and
combined groups
a
Main effects of Health intervention program using linear mixed effects model, adjusted for baseline scores
b
Main effects of Islamic intervention program using linear mixed effects model, adjusted for baseline scores
c
Interaction between health and Islamic program represents the additional effect of being in the combined group beyond the separate main effects presented for health and Islamic programs
d
p value for main effects from mixed effects model
e
p value for interaction between health x Islamic programs
f
ICC = Intra-class correlations coefficients, from mixed effects random intercept model
*Interaction health x Islamic were not assessed because main effects of health and Islamic were non-significant
**Non-estimable

Page 6 of 10
Tahlil et al. BMC Public Health (2015) 15:1088 Page 7 of 10

Fig. 2 Groups comparison in knowledge, attitudes, intentions and behaviors at 6 months follow-up

groups having significantly lower scores in smoking
attitude scores when compared to control groups.
Program effects on intentions to smoke tobacco at
6 months follow-up
Main effects and interaction effects of health and
Islamic-based intervention programs on intentions to
smoke tobacco at 6 months follow-up are presented in
Table 2. There was no significant main effects on intention
to smoke tobacco next year (OR = 0.4, 95 % CI = 0.1–1.3,
p = 0.14), during senior high school (OR = 0.4, 95 %
CI = 0.1–1.3, p = 0.13), and when older (OR = 0.5, 95 %
CI = 0.2–1.2, p = 0.13) for the health based intervention
programs at 6 months follow-up. Main effects of the
Islamic based intervention programs were not significant
on intention to smoke tobacco next year (OR = 0.4,
95 % CI = 0.1–1.6, p = 0.20), during senior high school
(OR = 0.3, 95 % CI = 0.1–1.2, p = 0.10), and when older
(OR = 0.6, 95 % CI = 0.2–1.4, p = 0.24) at 6 months
follow-up. The effects were more similar between partici-
pants within the same class for intention to smoke next
year (ICC = 0.12), during senior high school (ICC = 0.12),
and when older (ICC = 0.07). Groups’ differences in inten-
tions to smoke tobacco at 6 months follow-up are pre-
sented in Table 3 and Fig. 2. There were significant
differences (p < 0.001) between groups with respect to

Table 3 Outcomes at 6 months follow-up and comparison between intervention and control groups (n = 427)
Outcome measures Health (n = 109) Islamic (n = 101) Combined (n = 110) Control (n = 107) p – values
Health knowledge 11.3 ± 1.9*** 11.7 ± 2.0*** 10.9 ± 1.9*** 8.9 ± 2.4 <0.001
Islamic knowledge 11.5 ± 2.5 14.5 ± 1.6*** 12.0 ± 2.8 11.6 ± 2.2 <0.001
Smoking attitude 39.2 ± 7.9*** 34.9 ± 7.2*** 38.4 ± 6.6*** 41.4 ± 8.7 <0.001
Smoking intention next year 1.3 ± 0.8*** 1.0 ± 0.2*** 1.3 ± 0.6** 1.5 ± 0.8 <0.001
Smoking intention in senior high school 1.5 ± 0.6* 1.0 ± 0.2*** 1.4 ± 0.7*** 1.6 ± 0.8 <0.001
Smoking intentions when older 1.5 ± 0.6 1.2 ± 0.5*** 1.4 ± 0.7* 1.6 ± 0.8 <0.001
Past 7 days’ smoking behaviors 1.1 ± 0.4 1.0 ± 0.0 1.0 ± 0.0 1.1 ± 0.4 0.38
Past month’s smoking behaviors 1.1 ± 0.5 1.0 ± 0.0 1.0 ± 0.3 1.1 ± 0.4 0.14
Lifetime smoking behaviors 2.1 ± 2.2 1.2 ± 0.7* 1.4 ± 1.0 1.7 ± 1.3 0.01
Note: p values were obtained using ANCOVA tests, controlling for baseline. Total scores for health and Islamic knowledge ranged from 0 to 20, with higher scores
indicating greater knowledge; attitude scores ranged from 0 to 100, with higher scores indicated more favorable attitudes towards smoking; smoking intentions
scores ranged from 1 (“certainly not”) to 5 (“certain to smoke”); the past week smoking scores ranged from 1 (no cigarettes) to 6 (smoked six cigarettes or more);
the past month’s smoking behavior scores ranged from 1 (none) to 7 (smoked more than 20 cigarettes per day), and; the lifetime smoking behavior scores ranged
from 1 (never) to 9 (smoked more than 100 cigarettes)
*p < 0.05, **p < 0.01, ***p < 0.001, compared with control group. All values are presented as mean ± SD
Tahlil et al. BMC Public Health (2015) 15:1088
their intention to smoke tobacco next year, during senior
high school and when older, with the intention to smoke
significantly reduced in each of the three intervention
groups when compared to the control group (Table 3).
Program effects on smoking behaviors at 6 months
follow-up
Table 2 demonstrates main effects and interaction effects
between health and Islamic-based intervention programs
on smoking behaviors at 6 months follow-up. There was
a significant main effects on smoking behaviors in the
past 30 days for the health- (OR = 0.4, 95 % CI = 0.2–1.0,
p = 0.04) and Islamic-based interventions (OR = 0.1,
95 % CI = 0.0–0.8, p = 0.03) at 6 months follow-up but
the effects were insignificant in the past week and life-
time smoking behaviors for both the health and Islamic-
based interventions. The effects appeared to be more
similar between participants within the same class for
their smoking behaviors in the past week (ICC = 0.24),
past 30 days (ICC = 0.10) and lifetime (ICC = 0.15).
Groups’ differences in tobacco smoking behaviours at 6
months follow-up are presented in Table 3 and Fig. 2.
Compared to control group, the frequency of tobacco
smoking for the health and combined programs were
not significantly different in the past week, past 30 days,
and lifetime but differed significantly with those in the
Islamic-based interventions for the lifetime smoking
behaviors.
Discussion
This study was intended to assess the impact of three
types of school-based smoking prevention program
approaches namely the health, Islamic and combined
program amongst adolescents in the Aceh Province,
Indonesia on their smoking knowledge, attitude, inten-
tions, and behaviors at 6-month follow-up. Findings of
this study provide evidence that school-based smoking
prevention programs remained effective at a 6-month
post-interventions time-point.
An important finding of this study is significantly higher
scores on knowledge and those who had received Islamic-
or health-based education components, these groups
remained more knowledgeable than those in the compari-
son groups (non-health or non-Islam) at 6 months follow-
up. After initial effects in increasing knowledge scores for
participants in both the health and Islamic-based inter-
vention programs over 1 week of the programs comple-
tion [12], sustained effects were observed at 6 months
follow-up. This finding supports previous studies [25, 26]
regarding the long-term effectiveness of school-based
smoking programs on knowledge improvement. It must
be noted, however, that the combined program was not ef-
fective in retaining an increase in participants’ Islamic
knowledge at 6 months follow-up. Although students in
Page 8 of 10
the combined program had also been exposed with im-
portant concepts of the Islamic-based interventions
material, their Islamic knowledge scores were non-
significantly higher to those in the comparison group.
It appears, therefore that a consistent program of edu-
cation in Islam is required to achieve long-term pro-
gram effectiveness for this outcome.
Moreover, the three intervention programs improved
participants’ smoking attitudes at 6 months follow-up.
The inclusion of the health and Islamic based interven-
tion programs appeared to have a significant impact on
individual’s smoking attitudes at 6 months after program
completion. The reduction in mean smoking attitude
scores by 9.9 points (p < 0.001) for the health and 7.2
points (p < 0.01) for the Islamic based intervention
programs after 6 months intervention were larger than
immediately after the interventions, where it was equiva-
lent to shift of 5.8 points (p = 0.14) for the health and 5.3
points (p < 0.001) for the Islamic based intervention
programs. Previous studies have provided mixed conclu-
sions about program effects on smoking attitude. Al-
though some studies [26–28] found significant longer
term effects, others have not [25]. A religion-based inter-
vention has also been reported to have had a positive
impact on anti-smoking attitudes among students [29].
It is a general belief that religiosity/spirituality could
provide positive effects on adolescents’ health attitudes
[30]. Indeed, religion is perceived as an important aspect
of people’s lives [31], behavioral and lifestyle choice [29].
Our study also offers evidence for significant effects of
school-based programs in reducing smoking intentions
in the long-term. An evaluation immediately after the
end of the intervention programs showed some reduc-
tions in smoking intentions in next year, during senior
high school, and when older in the health and Islamic
based interventions [12]. Similar downward trends were
observed in the separate health and Islamic based inter-
ventions at 6 months follow-up. The findings suggest
that smoking intentions remained lower among partici-
pants in the three intervention programs than in the
control group at 6 months after the program interven-
tions completion. Although the combined health and
Islamic based intervention program failed to show sub-
stantial a reduction in tobacco smoking intentions, there
was evidence that the inclusion of Islamic-based compo-
nents provided benefits. Similarly, a previous study [32]
has indicated the effectiveness of a school-based program
in reducing smoking intentions at 6 months follow-up.
Additionally, it is important to note that the present study
involved Muslim adolescents only. While tobacco smok-
ing is considered as age-inappropriate [13] and religiously
forbidden behaviors for minors by the Indonesian Ulema
Council [33], the benefits of tailoring school-based pro-
gram interventions with participant’s religious background
Tahlil et al. BMC Public Health (2015) 15:1088
was also evidenced in this study. In fact, cultural sensitiv-
ity is an important factor for program effectiveness [34].
Our study appears to support long-term effectiveness
of school-based program on smoking behaviors. The
proportion of tobacco smoking was marginally lower
among participants in the three intervention programs
than in control group. Effects of the Islamic-based pro-
gram in reducing lifetime smoking behaviors were
stronger than in the other programs. Since smoking
rates at baseline were very low, the observed reductions
in the assessed smoking behaviors in the health and
Islamic-based programs were not detected as being sta-
tistically significant. Nevertheless, there was sufficient
evidence to suggest that both the health and Islamic-
based intervention programs provided almost similar
effects on the reduction of lifetime smoking behaviors
at 6 months follow-up. Findings from a systematic re-
view about long-term effectiveness of school-based
smoking prevention programs on smoking behaviors
have been less promising. While Wiehe et al. [9] found
that seven of eight studies in their review failed to de-
crease smoking behaviors among program participants
in long term, Flay [11] suggests and others [26, 35] have
found that school-based smoking prevention programs
can be effective longer term.
There were several limitations of this study including
the lack of biochemical validation for students’ re-
sponse toward self-report questionnaires; the relatively
short time evaluation (6 months) of program impact as-
sessment [12] and; the inclusion of study participants
from a relatively small geographical area. Data in the
current study relied upon students’ responses (self-report,
paper-based questionnaires) and the use biochemical tests
would be useful to ensure the validity of students’ re-
sponse toward questionnaire items regarding tobacco use.
Although the validity and reliability of survey items had
been verified and students had been informed about confi-
dentiality of response surveys, any biases associated
with the use of the self-report surveys might influence
this study’s findings.
This study reported program impacts at 6-months
follow-up and a longer-term assessment is required to
determine when program effectiveness may diminish.
There is still insufficient evidence about the longer-
term effects of school-based smoking prevention pro-
grams at present, especially in Indonesia.
Participants in this study were recruited from the
capital of the Aceh Province. Thus, its generalization to
other areas may be limited. Smoking prevalence differs by
geographic area and social economic status in Indonesia,
and predominates among males in rural areas [36], indi-
viduals with low education level [37], and amongst poorer
individuals [37]. Future study therefore should include
students from a broader area, with a larger participants
Page 9 of 10
(more schools per arm) and with a variety of religious
backgrounds. Such studies will broaden our under-
standing about the effectiveness of these programs,
including the strengths and weaknesses of the programs
when implemented in other populations. Although many
students benefited from this study, many more could also
benefit with an extended program. As has been stated [6]
the proportion of tobacco users across the community
levels is very high in Indonesia. Tobacco smoking has not
only been regarded as a culturally accepted behavior but
essential in the social and political lives of people in
Indonesia [38], For many young Indonesians, tobacco
smoking is viewed as part of identity and linked with so-
cial and cultural-religious practice [39]. Although some
positive progress have been made in tobacco control and
regulation in Indonesia including in tobacco advertise-
ment recently, the efforts remain in adequate and failed to
meet the WHO’s [5] recommendation for tobacco control
measures. Given these consideration, the successfulness of
this study could provide insight for policy makers and
boost the existing efforts in smoking prevention and ces-
sation program across the country, if any.
Conclusions
This is the first study to observe longer term effects of
school-based smoking prevention programs in Indonesia.
Findings provide further support that school-based pro-
grams can provide longer term effects on the improve-
ment of individual knowledge (Health-based program: β =
4.3 ± 0.4, p < 0.001 for health knowledge and β = 1.1 ±
0.4, p = 0.01 for Islamic knowledge. Islamic-based pro-
gram: β = 3.7 ± 0.4, p < 0.001 for health knowledge and
β = 2.2 ± 0.5, p < 0.001 for Islamic knowledge) and anti-
smoking attitudes (Health-based program: β = −11.5 ± 1.8,
p < 0.001. Islamic-based program: β = −6.0 ± 1.9, p < 0.01)
and the reduction of smoking behaviors among adoles-
cents (Islamic-based program: OR = 0.1, 95 % CI = 0.0 –
0.8, p = 0.03 for the past month smoking behaviors.
Health-based program: OR = 0.1, 95 % CI = 0.0 – 0.8,
p = 0.04 for the past month smoking behaviors). Health
and Islamic-based programs provided stronger effects and
while the separate health and Islamic-based approaches
showed similar effects, Tailoring intervention components
with participants’ religious background might be useful in
improving the long-term effectiveness of school-based
smoking prevention programs.
Competing interests
This study was supported by a Seeding Grant from the Faculty of Medicine,
Nursing and Health Sciences at Flinders University, Australia. The authors
declare no conflicts of interest.
Authors’ contributions
Authors’ contributions were as follows. TT wrote grant proposal for funding,
led study design, data collection and analysis, and wrote the first draft of this
paper. RW contributed in grant writing, helped design the study, participated
Tahlil et al. BMC Public Health (2015) 15:1088
in data analysis and interpretation, and reviewed and revised the manuscript.
JC involved in grant writing, participated in the study design, data collection,
interpretation, and reviewed and revised the manuscript. PW helped in grant
writing, study design, data collection, interpretation, and critically reviewed
and revised the manuscript. All authors have provided their agreement on the
manuscript for publication. All authors read and approved the final manuscript.
Acknowledgments
The authors wish to thank to program participants, providers, and other
involved parties for their contribution in this study.
Author details
1
Nursing Faculty, Syiah Kuala University, Banda Aceh 23111, Indonesia.
2
Flinders Centre for Epidemiology and Biostatistics, School of Medicine,
Flinders University, Adelaide, SA 5001, Australia. 3Discipline of Public Health,
School of Health Sciences, Flinders University, Adelaide, SA 5001, Australia.
Received: 23 December 2014 Accepted: 16 October 2015
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